October 2006

Contributed by readers/Edited by Donald B. Middleton, MD

HEEL HEALER

When the time comes to inject a painful calcaneal spur, Dr. Jerome Lebovitz from Pittsburgh, Pennsylvania, has a standard pain-limiting protocol. First he marks the area to be injected with a ballpoint pen and paints it with tincture of betadine. He then sprays it with ethyl chloride until the area appears snowy white and immediately injects 0.4 to 0.5 ml of 1% lidocaine using a 25-gauge needle inserted all the way down to the bone. After about two minutes, he injects 20 mg of methylprednisolone in another 0.5 ml of 1% lidocaine using a 23-gauge needle, again down to the bone. Dr. Lebovitz feels that the pain with this injection is minimal, although the procedure sometimes needs to be repeated to completely relieve the pain from the calcaneal spur. And he should know, because he trained his own medical assistant to do the procedure on him. The injection was nearly totally painless, he reports, and led to heel pain relief.

ONE-TWO PUNCH

To control bleeding from a puncture wound or small laceration in patients who have an elevated INR or other bleeding disorder, Dr. Jeff Rosenberg in Klamath Falls, Oregon, first gets the bleeding under control with direct pressure, silver nitrate application, or an injection of lidocaine with epinephrine. He then seals the wound with acrylic glue to prevent further bleeding. After the puncture wound is under control, he can investigate the cause of the bleeding disorder.

USING YOUR HEAD

To suture, staple, or glue a scalp laceration in an intoxicated or potentially violent patient, Dr. Gus Garmel in San Francisco, California, puts the patient in the prone position with the arms extended down the sides. Alternatively, he has the patient in the supine position with the folded arms tucked under the body. Either way, the patient’s head has to move first before a fist comes flying at him.

FAMILIAR RING

To remove a ring from an edematous or swollen finger, Mr. Chris May, a third-year medical student in Tempe, Arizona, removes watches or bracelets from the swollen extremity, elevates the hand above the heart, and loops a heavy suture under and around the ring. He liberally applies soap to the finger, then pulls out and distally on the suture so that it rotates around the ring, which slowly slips over the soapy finger. Each rotation allows an increment of progress to get the intact ring off without damaging it.

NOSE SPONGE

The traditional method of using cautery to control anterior epistaxis that has failed to respond to external compression leaves Dr. Brady Pregerson of Los Angeles, California, cold. Instead, he prefers to insert an expandable sponge into the anterior portion of the nose. He takes the sponge out of the sharp plastic insertion device in which it usually comes and coats it with antibiotic ointment. The lubrication makes the process of inserting the sponge less traumatic, and the antibiotic may help prevent complications from having the nose packed. After insertion, a few drops of oxymetazoline or phenylephrine added to the sponge will help induce local vasoconstriction. Dr. Pregerson often prescribes an oral antibiotic to keep the patient safe from problems such as toxic shock related to the sponge or packing in the nose.

COLORFUL SUGGESTION

Use blue suture material to repair scalp lacerations, advises Dr. Ramsey Hasan from Honolulu, Hawaii. Black gets lost in the hair, but blue stands out for both placement and removal.

BREATHE EASY

In an emergency, to rig up an “infield” tracheostomy, Dr. Ariel Marks in San Carlos, California, cuts off the reservoir drip chamber from an intravenous (IV) infusion tubing set, close to the tubing end. The pointed end that usually inserts into the IV bag is then inserted into the cricothyroid membrane while an ambu bag fitting is connected to the divided drip chamber to provide a simple substitute trach kit, allowing all to breathe easier.